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Earning two doctorates in a physician-scientist training program is a real accomplishment, but chances are that after graduation you will still be faced with several additional years of training before obtaining your first independent position. This article is about developing a successful strategy to cross the bridge that connects graduation and independence.

"If your career goal is to be in academia and do research, then you will need to complete your training as a physician and an investigator so that you can be employed in a setting where your choices--not those of your department chair--determine your career mix."

The message is about making decisions and asking yourself an important question: How do I want to spend my professional time 10 or more years from now? Ideally, planning should not wait until the summer before residency and postdoc applications are due. In fact, planning should begin soon after you begin the M.D.-Ph.D. program of your choice.

To demystify the path across the bridge, I have divided it into five steps: 1) deciding on your career goals, 2) deciding whether those goals require additional training, 3) deciding which clinical field (if any) best fits your goals and talents, 4) picking your residency (or postdoc) carefully, and 5) thinking like a department chair.

Step 1. Decide where you want to go before you go there.

As far as I know, there are no TV programs about the lives of physician-scientists; most of us who chose this career path did so because we encountered and became enchanted with the idea of integrating medicine and research. Many of us were fortunate to have role models who were "triple threats": successful researchers, doctors, and educators. Our goal was to be like them. The first big step in successfully traversing the bridge is deciding whether that is still your goal--then choosing a bridge that will take you there. Do you still want research and the quest for new knowledge to be the main focus of your career?

This is the question that causes every M.D.-Ph.D. program director to hold his or her breath as we await your answer. We want the answer to be a resounding "Yes!" because it validates our wisdom in selecting you and our success in mentoring you. However, the choice has to be yours, not ours. A research career can be wonderful, but you really have to want it. A recent survey of the alumni of 24 M.D.-Ph.D. programs, conducted by the National Association of M.D.-Ph.D. programs and the Association of American Medical Colleges Section on M.D.-Ph.D. Training, showed that about two-thirds (66%) of the alumni who had completed all of their training were in academia [1]. Another 14% were working at research institutes or in industry. Most reported spending at least some of their time doing research, but--and this is a critical point--only 65% of those in academia reported devoting at least half of their professional time to research. I would argue that although it is still possible to be a true chimera (physician, scientist, and educator), research has to be the top priority within the mix if it is important to you to succeed as an investigator. Choosing a mix in which a minor fraction of your time is set aside for research usually means that, eventually, you'll have zero time for research.

What does this have to do with traversing the bridge from M.D.-Ph.D. school to independence? You have to choose the right path as you cross the bridge. If your career goal is to be in academia and do research, then you will need to complete your training as a physician and an investigator so that you can be employed in a setting in which your choices--not those of your department chair--determine your career mix. If you have decided to be a full-time clinician, then your decision is primarily one of picking the clinical field that best fits your talents and interests.

Step 2: Decide if your goals require more training.

(Courtesy, Skip Brass)

Lawrence "Skip" Brass

For most, this is an easy decision. If you plan to practice medicine as even a small part of your career mix, you will need additional medical training, a license, and, in most cases, board certification. In the survey of M.D.-Ph.D. alumni mentioned above, nearly all (96%) chose to complete their clinical training by doing a residency or fellowship. Because nearly all M.D.-Ph.D. program alumni (about 90%) who are in academia have their primary appointment in a clinical department rather than in a basic science department, this makes perfect sense. On the other hand, it makes little sense to spend 3 to 5 years in full-time clinical training as a resident if you don't intend to use it--and don't forget that board certifications require regular renewal.

If you do intend to do research later, do you need more research training? Yes. Graduate school for scientists is like medical school for physicians: It's a great start, but not more than that. Mentored postgraduate research time is when you gain increasing independence, practice the skills you will need to run your own shop, and demonstrate to your future employer that your success as a graduate student wasn't a fluke.

Furthermore, depending on your interests, the research training you received in graduate school may not be broad enough, or it might not be the right kind. The typical current M.D.-Ph.D. student is training in a biomedical laboratory science. But when program alumni were asked to list the type(s) of research that they do, nearly as many checked the boxes for translational and patient-oriented research as for basic research. They may have done a thesis with a translational focus, but few will have received training in the requirements for doing modern patient-oriented research, which includes large doses of epidemiology, statistics, and human-subject trial design.

Step 3: Decide which clinical field (if any) best fits your career goals and talents.

If you decide that you wish to do both research and clinical care, then you should carefully consider your answers to the following questions before deciding on a clinical field:

Will my future department chief truly value research, or will he or she place a higher priority on clinical care? Some fields and some department chairs have a greater commitment to research than others. Some fields, especially those that are very procedure-oriented, demand considerably more practice time to maintain clinical proficiency. One can be proficient in a subspecialty of internal medicine or pathology with only intermittent clinical service time. It is harder to make the same statement about neurosurgery or any other field dominated by procedures that require constant practice. In theory, one can become a physician-investigator in any clinical field, but the data from the M.D.-Ph.D. survey show that some fields have done a better job of nurturing new investigators than others. It is not hard to find out this information for the fields that intrigue you. When you look around, ask how many of the M.D.-Ph.D. students who entered that field are still physician-investigators and how many of them ended up in private practice.

Will I have the very large amount of protected time needed to succeed as an investigator? Protected time will remain important throughout your career, but it is absolutely essential when you are getting started. If you are in a clinical department with large service requirements or with a high malpractice insurance rate, pressures on your protected time can quickly become overwhelming. If you intend to be in a clinical department, it is essential to consider its culture and values. In other words, you have to look beyond the glitz and consider what is actually going on.

Have I adequately explored my clinical choices from the faculty perspective and not just the medical student or resident perspective? The usual medical student experiences are unlikely to reveal much about the experience of being a faculty member in a particular field. Consider for a moment the typical physician-scientist attending on a pediatrics service. She may spend 80% of her time in her lab, 10% of her time teaching, and only 10% of her time on an inpatient service. Your contact with her may be limited to attending rounds, and your conversations will probably be about the patients that you share. In other words, you'll have a partial look at 10% of her professional life and no look at the other 90%. How can you make an important career decision without knowing more?

So take advantage of opportunities to spend extended time--beyond those limited clinical duties--with physician-scientists who work in clinical fields you are considering. Some M.D.-Ph.D. programs offer organized ways to do this, working with you to develop a list of areas that you wish to explore and then pairing you up with physician-scientists who are working in that area. At the University of Pennsylvania Medical School, we call this the Clinical Connections program. In the 6 years we have offered it, I have seen more students approach graduation with a clear choice of what to do next and far fewer with an undigested list of options and a look of desperation. If your program doesn't offer something similar, talk to your program director about other ways that you can get the career guidance that you need. These experiences will be enormously valuable as you narrow your choices. Don't wait until you have defended your thesis, returned to medical school, and are weeks away from submitting residency applications. Explore your options while you are in graduate school working on your thesis project.

Step 4: Pick your residency (or postdoc) carefully.

It is hoped that by the time you have reached step #4, you have decided whether you need to do a residency. If you have decided to forgo additional clinical training in favor of a postdoc, seek advice on the best labs in which to train. Start gathering this information well in advance of graduating. It is not unusual for popular labs to book postdocs a year in advance. How well you do as a postdoc will be critical to finding a job afterward. Prospective employers will want to know that you can be productive and successful as a scientist. Your selection of a mentor when you are a postdoc is critical. Seek someone with a strong record of success as an investigator and a mentor. Look for postdoctoral fellowships that are designed to encourage and develop independence and have at least the potential of a permanent position if things go well.

Chances are, however, that you will be heading off to a residency before returning to research as a fellow. If so, here are some points to consider: First, note whether the residency program views the training of future physician-scientists as an important part of its mission. Second, find programs that attract physician-scientists so that you won't be surrounded solely by future full-time clinicians. They may be terrific people, but their goals are different from yours.

If you intend to be a physician-investigator, one of your goals should be to get back to research as soon as possible. For most residents, it is unrealistic to think you can do meaningful research while working in a hospital 60 hours a week, including night call. But you can connect with the scientific community at the medical center where you are training by attending seminars, talking to investigators, and networking. When available, short-tracking your residency is an option worth considering. Short-tracking in a field like internal medicine (historically the most popular choice for future physician-scientists) means trading off a year of general internal medicine training for more time as a subspecialty fellow. As a future faculty member, your specialty training--not your generalist training--is far more likely to be what you will be doing clinically, so there are compelling reasons to get to it as quickly as possible.

Keep in mind that you don't have to do a residency and fellowship at the same place. You don't even necessarily have to do the clinical phase and the research phase of your fellowship at the same place, although you will have to complete all of the clinical requirements for board certification, and those will likely extend through your research years. Pick a clinical/research fellowship that offers access to great investigators and strong specialty training. Be sure to ask at your interviews whether you have the option of doing research with investigators in other departments and divisions. Always remember that your accomplishments during the research phase of your fellowship will be key to getting the job offer of your dreams.

A question that I hear frequently is whether graduating from an M.D.-Ph.D. program is an advantage when applying to residencies. The answer is an unequivocal "Yes, but. …" Accomplishments always count, but different clinical fields value research potential differently. Even if a department chair is hunting for future physician-scientists for the faculty, residency directors are usually clinicians. They are looking for capable candidates who can thrive as residents, take good care of patients, and not exacerbate the residency director's incipient ulcer. Especially in popular fields, they may use Step 1 of the United States Medical Licensing Examination board scores and grades in core clinical rotations to screen applicants within a large pool. If they look at your publication record at all, they probably won't do it until later in the process.

You have to have done well clinically to impress them. Doing well in research does not necessarily translate to doing equally well in the world of clinical medicine, where important decisions often have to be made quickly and based upon incomplete information. As mentioned above, some fields offer a physician-scientist track, which goes by many names. If so, view it as a plus but make sure the director of that track doesn't have to argue for admitting you to the residency despite your clinical performance as a 3rd-year medical student!

Step 5: Think like a department chair.

One of the really great things about a career as a physician-scientist is that you get paid to do something you love to do. Of course, to do that, someone has to hire you, protect your time for research, give you space, and provide a million-dollar start-up package. The good news is that jobs are likely to be there. (See also "The Job Outlook for Physician-Scientists.")

The number of individuals emerging from medical schools each year who become physician-scientists (M.D.-Ph.D. or M.D.) has barely been enough to maintain a steady level. Meanwhile, the age of the average physician-scientist continues to rise [2]. The number of people emerging from M.D.-Ph.D. programs per year (500 to 600) is small and shows little sign of increasing. If you divide this number by the number of clinical specialties, it becomes obvious why the competition for young physician-investigators with promise can be so fierce. As previously mentioned, most physician-scientists working in academia have their primary appointment in a clinical department. That is where the growth has been for the past 25 years [3].

So, if the jobs are there, what do you have to do to make sure that you exit the bridge years with an offer or two in your pocket? Think like a department chair. Hiring new tenure-track faculty members is expensive, and, at best, it will be several years before you can cover your costs by bringing in research grants. The people who hire you will want to be as certain as possible that you will succeed. The search committee members will ask themselves: How well did you do as a graduate student? Did you continue to do well when you reentered the lab as a postdoc/fellow? Have you acquired the skills needed to flourish as an independent investigator? Did you select (and complete) interesting projects? Have you published quality manuscripts? Do you write well and can you give a coherent seminar? Did you compete successfully for peer-reviewed training awards, such as the National Institutes of Health F-awards and K-awards? Will you arrive at your first faculty position with some grant funding in hand, or will you be starting from scratch?

Consider all of these questions yourself and, if the answers are not reflected in your CV, be prepared to address them in your cover letter and in an interview. Even better, recognize these generic issues as far in advance as possible and make sure that you receive the training and mentoring you need so you'll shine.

This means you should be very thoughtful about the mentor you choose when you reenter research. Does he or she have a track record of success that will create an environment in which you can thrive? Will his or her letter of recommendation carry a lot of weight? Mentors can help to open doors, including doors to job interviews. Ultimately, it will be up to you to succeed by working hard, but first the door has to open.

Final thoughts

If you are like most people emerging from an M.D.-Ph.D. program, you will enter the bridge years between graduation and independence somewhere in your late 20s and depart them in your mid- to late-30s. This is also a period when you may be getting married or starting a family. "Lifestyle" is a word that comes up frequently in conversations about residency choices for physicians, independent of whether they are physician-scientists. Everyone has to decide for themselves how they will balance their professional commitments with the other important parts of their lives.

My advice has always been that any career path that includes keywords such as "scientist" or "physician" is likely to be demanding. Combining them as a physician-scientist is not likely to be less demanding. Physicians in clinical practice can choose to work reduced hours, but current expectations placed on physician-scientists make that hard to do. Ultimately, you have to make the choice of what you will be and how you will do it. My goal as a program director and in this essay is to help you reach your goals and fulfill the dreams you had when you applied to physician-scientist training programs. I wish you the very best of success as you traverse the bridge to what for me remains a wonderful career.

Lawrence F. (Skip) Brass, M.D. Ph.D., is a professor of medicine and pharmacology and associate dean and director of the Medical Scientist Training Program at the University of Pennsylvania Perelman School of Medicine.